What are my treatment options?

Breast cancer treatment has improved greatly in the past 5-10 years. Care is now tailored to individual tumor types and patient needs.

The main components of the entire breast cancer treatment package include the following key elements:

• Breast Surgery

• Systemic Chemotherapy

• Radiation therapy (XRT)

• Endocrine Therapy

• Targeted therapy

If a breast imaging test shows an abnormality or you feel a lump, a biopsy is needed to diagnose cancer. This is usually a Core Biopsy, which takes a small sample from the tumor to identify its type and help plan your treatment. Treatment can differ for each person because no two tumors or patients are the same. Comparing treatments can be confusing, as small differences can significantly affect the approach.

While many people go straight to surgery after a diagnosis, chemotherapy is often recommended first for certain breast cancer types, such as Her2 Positive and Triple Negative. Dr. Green collaborates with a team of medical oncologists, radiation oncologists, other surgeons, and nursing staff to discuss your case and create the best treatment plan for your specific tumour.

What type of cancer do I have?

Breast cancer includes different types of tumors, mainly called Invasive Carcinoma. "Invasive" means that cancer cells have moved from the breast ducts and lobules into nearby tissue. Pathologists use this term when cells break out of these areas. However, "invasive" does not mean that the cancer has spread throughout the body; it means the cells are no longer inside the ducts (which is called Ductal Carcinoma in situ, or DCIS) and are now in the surrounding tissue, where they can reach lymphatic and blood vessels. This condition is classified as invasive carcinoma or breast cancer.

There are two common broad types of breast cancer that we see most of the time. There are also a number of less common variants that.

• Invasive carcinoma NST

• Invasive Lobular carcinoma

• Other subtypes - Tubular, mucinous, medullary, Papillary

The most common form of breast cancer is Invasive Carcinoma of no special type. This is standard breast cancer that diagnosed seen 75-85% of the time

Invasive lobular carcinoma makes up about 10-20% of breast cancers and behaves differently from invasive ductal carcinoma. It is often harder to find with standard imaging. After diagnosis, an MRI might be recommended to assess the tumor's size. There is also a higher chance of the tumor being found in the other breast, occurring in around 10% of lobular carcinomas versus 2% of invasive ductal carcinomas.

What is DCIS?

DCIS stands for Ductal Carcinoma In Situ, which is often referred to as pre-invasive carcinoma. In cases of DCIS, cancer cells develop within the lining of the breast ducts but remain confined to those ducts and do not spread beyond them into the surrounding breast tissue. Because these cells are contained strictly within the ducts, they do not have the ability to invade or reach blood vessels or lymph nodes in the body. However, if the cancer cells manage to escape the ducts, the condition then progresses to what is known as Invasive Carcinoma. Without appropriate treatment, DCIS can advance to Invasive Carcinoma, and research has shown that higher-grade DCIS tends to progress more quickly and aggressively compared to lower-grade forms. The standard treatment approach typically involves the surgical removal of the DCIS, followed by the application of breast radiation therapy (XRT) to significantly reduce the risk of the cancer returning in the future.

What type of surgery do I need?

Breast cancer surgery has two main parts.

• Surgery to the breast

• Surgery to the lymph nodes

There are two main types of breast cancer surgery.

• Breast conservation surgery

• Mastectomy

The type of breast surgery you need depends on several factors. The choice of surgery does not affect whether you will need chemotherapy. Some people mistakenly think that having a mastectomy means less chance of needing chemotherapy, but this is not true. The type of tumor plays a role in this decision.

What Factors influence the type of breast surgery needed?

• Breast size and tumour size

Removing over 10% of breast volume can lead to deformities. Oncoplastic techniques help avoid these problems, allowing for the removal of 20-30% of the breast. Smaller breasts often need these methods more to keep their shape. If a tumor is larger than 30-40% of the breast, a mastectomy is typically required. Sometimes, chemotherapy is used before surgery to reduce the tumor size, which may make oncoplastic surgery possible instead of a mastectomy.

• Number of tumours

If you have multiple tumors in the breast, known as multifocal breast cancer, especially in different areas, a mastectomy is necessary. When there are more than two tumors, an MRI is usually performed to determine if they are separate tumors or just one larger tumor that wasn't fully detected on the mammogram and ultrasound.

• Gene mutation

For younger patients with a BRCA 1 or 2 genetic mutation, a mastectomy can be beneficial even for small tumors. This option will be discussed with all patients under 40 who have a strong family history or a confirmed genetic mutation.

• Ability to have radiation

Breast conservation involves removing the tumor and some surrounding healthy tissue (lumpectomy) followed by radiation therapy. If you cannot have radiation or choose not to, breast conservation is not an option, and a mastectomy is advised. Without radiation after a lumpectomy, the chance of cancer returning in five years is 5-6 times greater than for those who receive radiation. Therefore, if you decline radiation, a mastectomy will be recommended.

Do my lymph nodes need to be removed?

If breast cancer spreads, it typically first reaches nearby lymph nodes in the armpit. Knowing the cancer stage and deciding on treatments like chemotherapy requires checking these lymph nodes for any cancer spread. Initially, the lymph nodes may appear normal on scans, which is a good sign. However, to confirm there are no cancer cells, certain lymph nodes need to be removed. This is known as a sentinel lymph node biopsy (SLNB).

A SLNB helps a pathologist examine lymph nodes closely to check for cancer spread. Several results can come from a sentinel node biopsy.

• No - cancer cells found - Negative lymph node

• a few cells measuring up to 0.2mm - Isolated tumour cells - Classed as a negative lymph node

• small clumps of cancer -0.2mm - 2mm - Micrometastasis - Positive involved involved lymph node

• large clumps of cancer cells >2mm - Macrometastasis - Positive Involved lymph node

Removing the lymph node helps determine if chemotherapy is needed. Usually, 1-4 lymph nodes are removed. If only one node has cancer, no further surgery is required, and radiation in the armpit may be suggested instead. Two methods are used to locate the node. First, a small radioactive protein is injected into the tumor on the morning of the surgery. This protein travels through the lymphatic system to the affected lymph node. A lymphoscintigraphy scan helps locate this node. During surgery, a probe detects the radiation to find the node. Additionally, while you are under anesthesia, blue dye (Patent Blue V) is injected into the nipple. This dye travels to the lymph nodes and turns the node blue, making it easier to identify alongside the radioactive protein. If there are multiple affected nodes or if cancer is spreading, further surgery called Axillary Lymph Node Clearance may be suggested.

• Axillary lymph node clearance (ALNC)

involves removing all lymph nodes from the armpit, usually between 10 to 40 nodes. This surgery is mainly required for serious cases with several affected nodes. If only one node is affected, doctors usually suggest radiation therapy instead to avoid problems like swelling in the arm (which can occur in 5-7% of patients severely and 20% mildly) and shoulder stiffness.

• Targeted axillary dissection (TAD)

A new method allows some patients with a cancerous lymph node to avoid full axillary clearance before surgery while receiving chemotherapy. If a cancerous node is found, a marker clip is placed in it. After chemotherapy, the cancer and lymph node may shrink or disappear, and a follow-up scan will assess treatment effectiveness. During surgery, a Sentinel node biopsy is performed to remove a lymph node that drains the breast area. The cancerous lymph node will also be removed using the marker clip. The Sentinel node and cancerous node often are the same. A pathologist will examine the removed nodes. If chemotherapy is successful, you may avoid axillary clearance, though radiation therapy will likely still be necessary.

Do I need Chemotherapy?

The decision for chemotherapy is quite complex. There is not one single factor that will be the decider for your need for chemotherapy or not.

A combination of the below factors will usually result in chemotherapy being offered.

• Grade 3

• Greater than 2cm

• triple negative (ER- PR- Her2 -)

• Her2 Positive

• Involved positive axillary nodes

• Young age <40 y

Chemotherapy can be administered prior to surgery, a treatment approach referred to as Neoadjuvant Chemotherapy (NACT), or it can be provided after the surgical procedure, which is known as Adjuvant Chemotherapy. We will have a comprehensive discussion with you regarding the best approach for your specific situation. Neoadjuvant therapy is typically recommended for aggressive tumor types, such as Her2 Positive or Triple Negative breast cancers. Additionally, this method may be employed for larger tumors or in cases where there are affected lymph nodes, as it can significantly aid in optimizing the surgical outcome.

What is Her2 Positive breast cancer (Her2+)?

Approximately 20% of breast cancers are classified as Her2 positive, which means they possess a specific protein that is closely linked to the growth and proliferation of cancer cells. This vital information is typically identified during a biopsy or surgical procedure, allowing for appropriate treatment planning. Her2 positive cancers are known to be more aggressive in nature and may exhibit early tendencies to spread to other parts of the body. Consequently, they are often treated with a combination of targeted therapy alongside chemotherapy to improve outcomes. The primary targeted drug used in this situation is Trastuzumab, commonly known by its brand name Herceptin, and in some treatment regimens, Pertuzumab, referred to as Perjeta, is also added for enhanced effectiveness.

Treatment for Her2 positive breast cancer generally begins prior to surgery, a process known as Neoadjuvant therapy, which aims to shrink tumors prior to the surgical intervention. Remarkably, in some cases, 60-70% of these cancers may be completely eradicated by the treatment. Following the surgical procedure, medical professionals evaluate whether the tumor has responded fully to the therapy, a measurement that is referred to as complete pathological response (cPR). Achieving cPR is associated with a positive long-term outlook for patients. However, if the tumor does not fully respond to treatment, the presence of remaining cancer cells indicates a partial response. In such scenarios, a second line of treatment utilizing Trastuzumab Emtansine, branded as Kadcyla, can be employed to further improve patient outcomes. Herceptin treatment is typically continued for a duration of 12 months following surgery, administered every three weeks, and is generally well tolerated by patients throughout the treatment period.

Do I need radiation therapy?

Radiation therapy is a crucial component of treatment following breast conservation surgery (BCS), as it significantly reduces the chance of cancer returning by approximately 5-6 times. In the case of a mastectomy, radiation therapy is usually not required unless there are serious risks associated with the surgery, such as the presence of a tumor larger than 5 cm, involvement of underlying muscle or skin, or multiple affected lymph nodes in the axilla. The process of radiation treatment itself is quite efficient and typically involves several sessions during which a small dose of radiation is administered each time, somewhat akin to going through an X-ray. Generally, the entire treatment regimen lasts about 3-5 weeks, with sessions conveniently scheduled from Monday to Friday. Certain patients, such as older adults or individuals who are in palliative care, may qualify for a shorter treatment schedule tailored to their specific needs. Importantly, radiation therapy is not painful and generally does not cause nausea; however, some patients may experience mild side effects such as skin redness in the treated area and a degree of fatigue.

What is Hormonal / Endocrine Therapy

70-80% of breast cancers respond to oestrogen, highlighting the hormone's significant role in the progression of the disease. Natural breast tissue utilizes oestrogen in

• Estrogen Receptor: ER+

• Progesterone Receptor: PR+

If you are positive for these receptors, hormonal therapy is likely recommended. This treatment involves taking a tablet for 5-10 years after surgery to block oestrogen, depending on whether you're pre-menopausal or post-menopausal.

• Pre-menopausal: Tamoxifen

• Post-menopausal: Aromatase inhibitors (Anastrazole/Arimidex, Letrozole/Femara)

If your tumor lacks both estrogen and progesterone receptors, it is classified as hormonal negative breast cancer. In the event that it is also negative for the HER2 protein, it is specifically referred to as Triple Negative Breast Cancer (TNBC). In such cases, there are no targeted hormone therapies available for treatment, which means that chemotherapy is typically recommended and administered, often prior to the surgical intervention.

How do I Know the tumour hasn’t spread?

Most breast cancer cases are typically discovered at an early stage and demonstrate a favorable outlook, boasting an impressive 91% survival rate over a span of 10 years. If the cancer remains small and has not extended to nearby lymph nodes, the risk of it metastasizing is considerably low. As a result, routine scans performed prior to surgery are generally not necessary in these situations. However, in more advanced cases where the cancer is larger or exhibits aggressive characteristics, and especially when lymph nodes are involved, the likelihood of spreading significantly increases. In such scenarios, staging scans become essential diagnostic tools. These scans include:

• PET CT (most common)

• Bone Scan

• CT of Chest, Abdomen, Pelvis, or Brain